Safety

Expect more life safety issues in your next survey

Hospital Safety Insider, April 13, 2017

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If the results from your next survey include more life safety compliance issues than you’re used to, don’t fret. They’re likely the result of surveyors tweaking the way they operate, at the request of CMS.

Accrediting organizations, such as The Joint Commission, used to be permitted to consider a hospital’s plan for improvement (PFI) when assessing common deficiencies, but not any longer. Under the revised protocol, facilities will have 60 days to correct their life safety compliance problems and must submit to an official observation.

“We realize that this change will have a major impact to the survey report from previous surveys, and we want to reassure you that in most cases additional findings on the report does not mean the facility has declined in maintenance or compliance,” the American Society for Healthcare Engineering (ASHE) said this week in a memo to hospital and health system executives.

Doors are among the items likely to be affected by the change, ASHE noted. Although most facilities have implemented management and documentation programs to check doors frequently for compliance, surveyors will no longer be permitted to consider the engineering staff’s records in determining whether to issue a citation. Any door that fails to meet the standard must be cited.

For the latest tips and advice on this and similar topics affecting healthcare facility managers, plant operations professionals, and directors of engineering, be sure to subscribe to HCPro’s Healthcare Life Safety Compliance.



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